The Curbsiders Podcast: REBOOT #469 Inpatient Heart Failure

Release Date: February 9, 2026
Guest: Dr. Grisha Pandrath, Advanced Heart Failure and Transplant Cardiologist

Episode Overview

This episode revisits the essentials and nuances of managing inpatient heart failure (HF), featuring expert Dr. Grisha Pandrath. The conversation covers the full arc of the inpatient HF journey: from diagnosis and workup to decongestion strategies, guideline-directed therapy, patient education, and transitions of care. The discussion is rich with clinical pearls, practice-changing approaches, and pragmatic advice, ideal for any clinician managing hospitalized HF patients.

Key Discussion Points & Insights

1. Initial Patient Presentation and Diagnosis

• Case Introduction ([09:25]): 64F with shortness of breath, peripheral edema, hypertension, and signs of volume overload.
• Pearl: Always confirm if the presentation is truly HF or a mimic. "Everything which is somebody is short of breath or has leg swelling, you really have to go through those differentials." (Dr. Pandrath, [11:04])
• Use the universal definition of heart failure—integrate clinical, biomarker, and imaging data.
• Don’t forget to assess for alternative or concurrent causes (e.g., hepatic disease, thyroid disease, arrhythmias).

Role of Point of Care Ultrasound (POCUS) ([13:42])

• "The point of care ultrasound...the role for it has been emerging quite a bit...You can look at the structure of the heart, IVC distension, and look for pericardial effusion or tamponade." (Dr. Pandrath, [13:42])
• POCUS adds diagnostic confidence, especially when the case isn’t straightforward.

When to Get Echocardiography ([19:27])

• New Diagnosis: Always get an echocardiogram to guide therapy and understand LV structure.
• Known HF Patient: Only repeat if the findings will change management (e.g., unexpected hypotension, suspected valvular pathology, unresponsive to therapy).
• Volume status can alter apparent valve regurgitation; reassess after decongestion.

"Only get a repeat echo if you have a question that will change your management." (Dr. Pandrath, [19:57])

2. Decongestion and Diuretic Strategies ([25:20])

• Initial Approach (Diuretic-naive):
  • Furosemide 20–40mg IV bolus; titrate based on response, renal function, and degree of overload.
  • In hypertensive patients, afterload reduction should occur hand-in-hand with decongestion.
• Escalate rapidly if inadequate response:
  • Increase dose and/or frequency.
  • Consider continuous infusion if multiple boluses are ineffective.
  • Use spot urine sodium to assess diuretic response.
• Adjuncts:
  • Switch to or add other loop diuretics (e.g., torsemide, bumetanide) if resistance.
  • Add a thiazide diuretic (e.g., chlorthalidone, metolazone) for sequential nephron blockade.

Notable Guideline Reference

• Recent 2023 Acute Heart Failure Management Document provides “bite-size, very practical advice." ([28:43])

SGLT2 Inhibitors and Adjuncts ([34:53], [36:46])

• SGLT2i (e.g., dapagliflozin, empagliflozin) now have clear benefit for both additional diuresis and disease modification, with little impact on blood pressure—start early if GFR permits.
• "Early use of SGLT2 inhibitors...will help you..." ([34:53])
• Prefer SGLT2i to adjunct diuretics (e.g., acetazolamide), but acetazolamide remains an option if profound resistance.

Afterload Reduction ([38:08])

• Decongest first, but don't neglect blood pressure management, especially if presenting very hypertensive.
• Beta-blockers and ARNI/RAASi should be started only when stable and euvolemic.

Monitoring Response ([39:36])

• Reliable measurement of ins and outs is essential, though difficult.
• "Cheap way" is to use daily weights, but interpret with caution in long-stay or malnourished patients.
• In select cases, implantable pulmonary artery monitors may help with high-risk, frequently readmitted patients.
• Enlist patients in tracking their outputs when possible—"patients get super excited to be able to contribute." ([45:09])

Fluid and Sodium Restriction ([47:09])

• Evidence is mixed, but prudent restriction (≤2g sodium, 48–64oz fluid) is reasonable.
• Don't over-restrict to the point of harming nutrition, especially in elders.

3. Classification and Guideline-Directed Therapy

Staging ([49:40])

• Use both HF type and ACC/AHA stage (A–D).
• For our case: HFrEF (EF < 40%) and stage C.

The Four Guideline Pillars ([53:01])

1. Beta-Blocker
2. SGLT2 Inhibitor
3. ARNI/ACEi/ARB (preferably ARNI if possible)
4. Aldosterone Antagonist (MRA)

• "The most tolerable medication would be an SGLT2 inhibitor..." (Dr. Pandrath, [73:42])

Initiation Sequence:

• SGLT2i and MRA can often be started first (blood pressure agnostic).
• ARNI/RAASi next, as tolerated (pay attention to BP and renal function).
• Start beta-blocker last, and never on the day of discharge—should trial for at least 24 hours prior to leaving hospital. ([55:27])
• For those who go into shock, delay beta-blocker initiation until full stabilization.

In HFpEF

• SGLT2 inhibitors for all.
• ARNI only for certain subgroups (by gender, EF).
• MRAs for select patients with congestion/re-hospitalization risk.
• Beta-blocker only if another clear indication (arrhythmias, CAD).

"Low Dose of All vs. High Dose of Some" ([75:00])

• Always favor low doses of all four in-hospital, rather than pushing the dose of just a few.

  "Low dose of all is much superior than higher dose of a few because...you're getting additive benefit of different pathways." (Dr. Pandrath, [75:20])

4. Escalation, Shock, and Advanced Therapies

When Shock Develops ([65:23])

• Declining blood pressure, rising heart rate, low urine output, and cool extremities should prompt immediate concern for cardiogenic shock.
• Don’t delay escalation: consider pulmonary artery catheterization and start inotropes or vasopressors when indicated.
• Pause neurohormonal blockers during shock.

Inotrope/Vasoactive Choices ([69:02])

• Dobutamine or milrinone for inotropy (milrinone less favorable with hypotension or tachycardia).
• Vasopressors only if critically hypotensive; dopamine if bradycardic, but risky with tachycardia.
• If high BP and shock, consider pure vasodilator (e.g., nitroprusside).

Right Heart Catheterization ([71:49])

• Indicated if:
  • Hypotensive or shocky
  • Refractory to therapy
  • Worsening kidney function without clear reason
  • Symptom progression despite escalation

5. Transition of Care & Discharge

Pre-Discharge Medication Strategy

• Focus on low doses of all four classes.
• Ensure carefully adjusted loop diuretic dose, especially if diuresed aggressively or started on MRA/SGLT2i (which may also have diuretic effect).
• For elderly or fragile patients, tailor therapy with extra caution—orthostatics can help detect risk for post-discharge instability.
• Ensure beta-blockers are not started the day of discharge.

Washout Period ([82:38])

• When converting ACEi to ARNI, 36-hour washout is essential to avoid angioedema. If this prolongs LOS or is impractical, consider starting ARB with easier transition to ARNI later.

Cost/Access Considerations ([83:18])

• ARNI often costly; use ARB/ACEi if patient cannot access ARNI, but actively leverage patient assistance programs where possible.

Prompt Outpatient Follow-Up ([81:07])

• Discharge clinics or close follow-up (ideally within 1 week) are critical for early adjustment of therapy, rechecking labs, and preventing readmission.

Patient Education ([85:07])

• Begin education during hospitalization. Use a team approach: repeated, layered info about self-monitoring, signs of decompensation, purpose/side-effects of each med, and importance of adherence and follow-up.
• "If they're aware, that panic level goes away." (Dr. Pandrath, [85:31])

Notable Quotes & “Memorable Moment” Timestamps

• On SGLT2 inhibitors:

  • "The SGLT2 is the statin for heart failure." (Dr. Pandrath, [65:16])
  • "SGLT2s for everyone!" (Dr. Amin, [65:04])

• On rapid therapy escalation:

  • "If you know somebody’s overloaded, don’t...massage the same thing till death...escalate therapy quickly." (Dr. Pandrath, [88:51])

• On discharge safety:

  • "Beta blocker should not be started the day of discharge on the way out of the hospital." (Dr. Pandrath, [55:27])

• On team-based education:

  • "One person—the hospitalist, the cardiologist—is not enough...it needs recurrent reinforcement." (Dr. Pandrath, [85:31])

Suggested Timestamps for Key Segments

• Case Presentation and Diagnostic Workup: [09:25]–[15:15]
• Echocardiogram Guidelines, Repeat Imaging: [19:27]–[24:59]
• Diuretic Choices and Escalation: [25:20]–[34:53]
• SGLT2 Inhibitor and Adjunct Therapy: [34:53]–[37:42]
• Afterload Reduction and Monitoring Fluid Balance: [38:08]–[47:09]
• Medication Initiation Strategy: [53:01]–[57:58]
• Managing Shock: [65:23]–[73:09]
• Transition of Care Essentials: [73:42]–[88:39]
• Take-Home Messages: [88:39]–[90:33]

Top Three Take-Home Points (Dr. Pandrath, [88:51])

1. Decongestion: Act fast, escalate quickly if diuretic response is suboptimal—don’t linger on ineffective regimens.
2. Guideline-Directed Therapy: Get as many of the four pillars on board at low doses, as early as feasible, particularly SGLT2 inhibitors and MRAs, mindful of BP and renal status.
3. Transitions and Education: Robust discharge planning, clear patient education, and swift outpatient follow-up are essential to avoid readmissions and improve outcomes.

Original Curbsiders style and camaraderie kept the episode engaging and practical, loaded with real-world strategies and pearls. If you only take away one thing: Start SGLT2 inhibitors early, escalate diuretics without delay, and never underestimate the power of good patient education and thoughtful transitions of care.